A critical link between heart failure self-care and intrathoracic impedance

Psychometric properties of the Persian version of the European heart failure self-care behavior scale

Objective

To investigate the psychometric properties of the self-care behavior scale in heart failure (HF) patients. The development of self-care behaviors is one of the goals of non-pharmacological care management programs.

Methods

After translating the European Heart Failure Self-care Behavior scale (EHFScBS), validity was assessed through explanatory factor analysis; additionally, reliability was assessed through Cronbach alpha and test–retest. The samples comprised of 120 HF patients admitted to hospitals in Tehran during 2017–2018.

Results

The mean age of the samples was 67.3 ± 14.04 years. Fifty-four patients (45%) were female. All items of the scale had an acceptable factor loading. Cronbach alpha coefficient was 0.72. The intra-cluster correlation coefficient (ICC) was 0.69.

Conclusions

Nurses and clinicians could benefit from the Persian version of HF self-care scale since it would enable them to rapidly assess patients’ self-care behaviors and to evaluate the effectiveness of the HF management.

Self-Care Monitoring of Heart Failure Symptoms and Lung Impedance at Home Following Hospital Discharge: Longitudinal Study

Background

Self-care is key to the daily management of chronic heart failure (HF). After discharge from hospital, patients may struggle to recognize and respond to worsening HF symptoms. Failure to monitor and respond to HF symptoms may lead to unnecessary hospitalizations.

Objective

This study aimed to (1) determine the feasibility of lung impedance measurements and a symptom diary to monitor HF symptoms daily at home for 30 days following hospital discharge and (2) determine daily changes in HF symptoms of pulmonary edema, lung impedance measurements, and if self-care behavior improves over time when patients use these self-care monitoring tools.

Methods

This study used a prospective longitudinal design including patients from cardiology wards in 2 university hospitals—one in Norway and one in Lithuania. Data on HF symptoms and pulmonary edema were collected from 10 participants (mean age 64.5 years; 90% (9/10) male) with severe HF (New York Heart Association classes III and IV) who were discharged home after being hospitalized for an HF condition. HF symptoms were self-reported using the Memorial Symptom Assessment Scale for Heart Failure. Pulmonary edema was measured by participants using a noninvasive lung impedance monitor, the CardioSet Edema Guard Monitor. Informal caregivers aided the participants with the noninvasive measurements.

Results

The prevalence and burden of shortness of breath varied from participants experiencing them daily to never, whereas lung impedance measurements varied for individual participants and the group participants, as a whole. Self-care behavior score improved significantly (P=.007) from a median of 56 (IQR range 22-75) at discharge to a median of 81 (IQR range 72-98) 30 days later.

Conclusions

Noninvasive measurement of lung impedance daily and the use of a symptom diary were feasible at home for 30 days in HF patients. Self-care behavior significantly improved after 30 days of using a symptom diary and measuring lung impedance at home. Further research is needed to determine if daily self-care monitoring of HF signs and symptoms, combined with daily lung impedance measurements, may reduce hospital readmissions.

Self-care Moderates the Relationship Between Symptoms and Health-Related Quality of Life in Heart Failure

BACKGROUND

Physical symptoms and depression in heart failure (HF) are key drivers of health-related quality of life (HRQOL). Heart failure self-care behaviors are believed to influence how symptoms affect HRQOL.

OBJECTIVE

The goal of this study was to determine if HF self-care behaviors moderate the relationships between physical and depressive symptoms and HRQOL.

METHODS

In a cohort of adults with moderate to advanced HF, multivariate linear regression was used to evaluate the interaction between self-care behaviors (Self-care of HF index maintenance and management scales) and physical HF symptoms (HF Somatic Perception Scale) on emotional HRQOL (emotional dimension of Minnesota Living With HF Questionnaire). The interaction between self-care behaviors and depression (9-item Patient Health Questionnaire) was evaluated on physical HRQOL (physical dimension of Minnesota Living With HF Questionnaire).

RESULTS

The mean age of the sample (N = 202) was 57 ± 13 years, 50% were women, and 61% had New York Heart Association class III or IV HF. Controlling for age, Seattle HF score, functional ability, and comorbidities, self-care maintenance and management moderated the relationship between physical HF symptoms and emotional HRQOL. Only self-care maintenance moderated the relationship between depression and physical HRQOL.

CONCLUSION

In HF, HRQOL is dependent on both the severity of physical and depressive symptoms and the level of engagement in HF self-care behaviors. Future research should consider both self-care behaviors and symptoms when examining patient HRQOL.

Device-detected congestion is associated with worse patient-reported outcomes in heart failure

BACKGROUND

Congestion is a common cause of symptoms in heart failure (HF). Yet, intrathoracic impedance, an objective marker of cardiopulmonary congestion, has not been examined in relation to HF symptoms.

OBJECTIVE

To determine whether device-detected cardiopulmonary congestion is a predictor of physical and psychological symptoms and health-related quality of life (HRQOL) in adults with HF over 3 months.

METHODS

Multivariate generalized linear modeling was used to quantify the association of cardiopulmonary congestion (Optivol^® Index exceeding 60 Ω threshold) with HRQOL (12-item Kansas City Cardiomyopathy Questionnaire) and both physical symptoms (Functional Assessment of Chronic Illness Therapy-Fatigue Scale; HF Somatic Perception Scale Dyspnea and Early & Subtle Symptoms subscales) and affective symptoms (9-item Patient Health Questionnaire; 6-item Patient-Reported Outcomes Measurement Information System Anxiety Scale).

RESULTS

The mean age of the sample (n = 49) was 62years old, 39% were women, and 63% had NYHA class III/IV HF. Participants who experienced threshold crossings in the previous 90days reported on average, 130% higher dyspnea (p = 0.017; confidence interval (CI) 10.2%, 437%), 40% higher early & subtle symptoms (p = 0.029; CI 3.4%, 89.7%), 106% higher depressive symptoms (p = 0.003; CI 19.1%, 257%) and 40% higher anxiety (p = 0.028; CI 3.7%, 89.1%). Threshold crossings in the previous 90days were also significantly associated with a clinically meaningful decrease in HRQOL (β = -16.16 ± 6.32; p = 0.01).

CONCLUSIONS

Intrathoracic impedance measured with the Optivol Index can provide additional information regarding the patient experience of hallmark physical and psychological HF symptoms and HRQOL over 3months.

Dimensionality and reliability of the self-care of heart failure index scales: further evidence from confirmatory factor analysis

The Self-Care of Heart Failure Index (SCHFI) is used widely, but issues with reliability have been evident. Cronbach alpha coefficient is usually used to assess reliability, but this approach assumes a unidimensional scale. The purpose of this article is to address the dimensionality and internal consistency reliability of the SCHFI. This was a secondary analysis of data from 629 adults with heart failure enrolled in three separate studies conducted in the northeastern and northwestern United States. Following testing for scale dimensionality using confirmatory factor analysis, reliability was tested using coefficient alpha and alternative options. Confirmatory factor analysis demonstrated that: (a) the Self-Care Maintenance Scale has a multidimensional four-factor structure; (b) the Self-Care Management Scale has a two-factor structure, but the primary factors loaded on a common higher-order factor; and (c) the Self-Care Confidence Scale is unidimensional. Reliability estimates for the three scales, obtained with methods compatible with each scale's dimensionality, were adequate or high. The results of the analysis demonstrate that issues of dimensionality and reliability cannot be separated. Appropriate estimates of reliability that are consistent with the dimensionality of the scale must be used. In the case of the SCHFI, coefficient alpha should not be used to assess reliability of the self-care maintenance and the self-care management scales, due to their multidimensionality. When performing psychometric evaluations, we recommend testing dimensionality before assessing reliability, as well using multiple indices of reliability, such as model-based internal consistency, composite reliability, and omega and maximal reliability coefficients.

Device diagnostics and early identification of acute decompensated heart failure: a systematic review

BACKGROUND

Traditional methods of heart failure (HF) management are based on reactive strategies to treat late indicators of decompensated HF. Advances in monitoring methods have become available with the evolution of implantable cardioverter-defibrillators and cardiac-resynchronization therapy devices. These devices provide new diagnostic data and remote monitoring capabilities that allow clinicians to proactively monitor patients for earlier signs of worsening HF. The integration of data obtained from implantable cardioverter-defibrillator and cardiac-resynchronization therapy technology could improve outpatient HF care, potentially leading to decreased readmission rates and improved patient outcomes.

OBJECTIVE

This review will synthesize the literature regarding the efficacy of device diagnostic data and the usability of the data in the clinical setting.

METHODS

Articles for review were obtained using Cumulative Index to Nursing and Allied Health Literature, MEDLINE, PubMed, and ClinicalTrials.gov.

RESULTS

Device diagnostics showed strong correlation with established HF biomarkers and hemodynamic measures. The findings from this review indicate that device diagnostic parameters predict impending HF much earlier than traditional methods of monitoring do. Device diagnostics are also more accurate in the early prediction of HF when compared with noninvasive objective measures, particularly when multiple parameters are combined and monitored for trends. Device diagnostics possess a distinct advantage over traditional methods of monitoring for HF because they allow clinicians to remotely monitor the status of their HF patients without relying on patient compliance for data entry and reporting.

CONCLUSIONS

Studies regarding the efficacy of device diagnostic parameters suggest that their integration into clinical practice will provide a more accurate and reliable mechanism for assisting clinicians in risk stratifying and predicting potential episodes of decompensated HF.

Profiles of self-care management versus consulting behaviors in adults with heart failure

INTRODUCTION

Patients with heart failure (HF) vary in their ability to respond to symptoms when they occur. The goal of this study was to classify common patterns of symptom response behaviors among adults with HF and identify biobehavioral determinants thereof.

METHODS

Consulting behaviors (i.e. contacting a provider for guidance) were measured using the European Heart Failure Self-care Behavior Scale consulting behaviors subscale, and self-care management (i.e. recognizing and engaging in self-initiated treatment of symptoms) was measured with the Self-Care of HF Index self-care management scale in a prospective cohort study. Latent class mixture modeling was used to identify distinct profiles of consulting and of self-care management behaviors.

RESULTS

The mean age (n=146) was 57±13 years, 30% were female, and 59% had class III/IV HF. Two distinct profiles of consulting behaviors (novice and expert) and three distinct profiles of self-care management (novice, inconsistent and expert) were identified. There was a weak association between profiles of consulting behaviors and self-care management (Kendall's tau-b=0.211). Higher levels of anxiety were associated with worse consulting behaviors (β=1.67±0.60) and worse self-care management (β= -5.82±3.12) and lower odds of exhibiting expert level consulting behaviors (odds ratio (OR)=0.50; 95% confidence interval (CI)=0.26-0.95) and self-care management (OR=0.47; 95% CI=0.24-0.92) (all p<0.05). Higher levels of physical symptoms were associated with better self-care management (β=0.50±0.12; OR =1.02, 95% CI=1.00-1.05; both p<0.05).

CONCLUSIONS

Expertise in consulting behaviors does not necessarily confer expertise in symptom self-care management and vice versa. Physical and psychological symptoms are strong determinants of symptom response behaviors.

Threshold crossing of device-based intrathoracic impedance trends identifies relatively increased mortality risk

AIMS

Threshold crossings of impedance trends detected by implanted devices have been associated with clinically relevant heart failure events, but long-term prognosis of such events has not been demonstrated. The aim of this study is to examine the relationship between alterations in intrathoracic impedance and mortality risk in patients with implantable devices.

METHODS AND RESULTS

We reviewed remote monitoring data in the de-identified Medtronic CareLink(®) Discovery Link that captured intrathoracic impedance trends for >6 months. The initial 6 months of the cardiac and impedance trends were used as the observation period to create the patient groups and cross-referenced with the Social Security Death Index for mortality data. In our study cohort of 21 217 patients, 36% experienced impedance threshold crossing within the initial 6 months of monitoring (defined as the 'early threshold crossing' group). Patients with early threshold crossings demonstrated an increased risk of age- and gender-adjusted all-cause mortality [hazard ratio (HR) 2.15, 95% confidence interval (CI) 1.95-2.38, P< 0.0001]. Increased mortality risk remained significant when analysed in subgroups of patients without defibrillator shock (HR 2.10, 95% CI 1.90-2.34, P< 0.0001, n= 1621) or within those patients without device-detectable atrial fibrillation (AF) during the initial 6 months of monitoring (HR 2.09, 95% CI 1.86-2.34, P< 0.0001, n= 17 235). Both the number and the duration of early threshold crossings of impedance trends detectable by implanted devices were associated with increased mortality risk. Furthermore, the improvement of altered impedance trends portends more favourable prognosis.

CONCLUSIONS

Threshold crossing of impedance trends detectable by implanted devices is associated with relatively increased mortality risk even after adjusted for demographic, device-detected AF, or defibrillator shocks.

Self care in patients with chronic heart failure

'Heart failure self care' refers to the practices in which patients engage to maintain their own health, and to the decisions that they make about managing signs or symptoms. In this article, we base our discussion of self care in chronic heart failure on the classification of patients as being 'expert', inconsistent', or 'novice' in heart failure self-care behaviors. The available literature on factors predicting heart failure self care and its outcomes are reviewed within this context. Factors known to influence heart failure self care include experience with the illness, physical functioning, depression and anxiety, social support, daytime sleepiness, and attitudes such as confidence. Further research is needed to understand the contributions of comorbidities, patient sex, and health disparities on heart failure self care. The evidence to support a link between heart failure self care and health outcomes is limited, but early evidence suggests that adequate self care is associated with an improvement in health status, a decrease in the number and duration of hospitalizations, and a decline in levels of biomarkers of stress and inflammation, and in intrathoracic impedance. Implications of heart failure self care for clinical practice, policy, and public health are also described.